QD - Extra Fees Form (Single)

This Payment Form is for client requests or edits that take more than 5 minutes and are outside their Support or Subscription Agreement.

These can include services relating to:

Extra Form Fees,
Data Services Fees,
Ad Hoc Support Fees, or
Special Services.

Practice Name*

Practice Website*

Mobile Number*

Email*

My Products

Extra Fees (single)As agreed, this is a single fixed fee (excl GST)

$100.00AUD

Extra Fees (single)As agreed, this is a single fixed fee (excl GST)

$200.00AUD

Subtotal

$0.00AUD

Tax

$0.00AUD

Total

$0.00AUD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I understand and accept:*

Quantum Digital's General & Form Terms - www.quantumdigital.com.au/terms-of-service & www.quantumdigital.com.au/adv-form-termsDue to hosting, data storage, and ongoing maintenance costs, the annual subscription for my service will recur on the anniversary of the this order.